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We hypothesized that patients with hemophilia or von Willebrand disease might be protected from atherosclerosis because of their coagulation defect. We studied 40 subjects affected by these two coagulation diseases using echocolor Doppler of the abdominal aorta and leg arteries, and compared the results with those obtained in 40 control patients who were homogenous with study patients in terms of sex, age, and risk factors for atherosclerosis. The probands presented a lower number of plaques than the 40 control subjects in the aorta and in the leg arteries. The most serious hemophilic patients had fewer plaques than controls or than patients with mild hemophilia. Both hemophilia and von Willebrand disease seem to protect against atherosclerosis.

Haemophilia B patients with factor IX (FIX) activity < 1% are usually characterized by severe bleeding episodes early in life. We report a case of sporadic severe haemophilia B, clinically characterized by mild bleeding diathesis. The presence of anamnestic thrombophlebitis in the patient's mother prompted us to investigate a possible associated hypercoagulable condition. Resistance to activated protein C due to factor V R506Q mutation was present in the mother and in the propositus, in the homozygous and heterozygous form, respectively. Molecular analysis of the FIX gene led to the identification of a nonsense mutation resulting in a stop codon at position 50, previously described and usually responsible for a severe pattern of haemophilia B. The implications of this unusual association are discussed.

The association between gastrointestinal angiodysplasia and von Willebrand disease was reported 30 years ago. The clinical course of patients with von Willebrand disease and angiodysplasia is characterized by numerous admissions to hospital for gastrointestinal bleeding necessitating transfusion with packed red cells, factor VIII and plasma. The management of these patients is problematic. Numerous treatments for the gastrointestinal bleeding have been proposed: surgery, electrocoagulation, laser photocoagulation, sclerotherapy, arteriography with embolization, immunoglobulins, oestrogens, and octreotide, but no treatment modality has been successful in all cases. We report a 66-year-old-female with small bowel angiodysplasia and von Willebrand type III disease in whom prompt administration of factor VIII/vWF concentrates was effective. Education of patients to recognize minimal gastrointestinal bleeding manifestations, periodical clinical visits and early infusion of factor VIII/vWF seems to be fundamental for the success of this therapy. A longer follow-up and the study of other patients are needed to confirm our observation.

Thirteen female patients with the prothrombin 20210 G-A abnormality (twelve heterozygotes and one homozygote) were selected out of 551 patients admitted to our Department of Medicine or to our Outpatient Hemostasis Units between January 1999 and October 2000. The selection was based on the fact that all patients had taken or were still taking oral contraceptives (OC) for a period of 3 years or longer than 3 years. None of these patents as gathered from history, physical examination, private physician records and our records has shown any DVT during or immediately after OC intake. Physical and compression ultrasonography examinations at the time of study were all negative. The average length of oral contraceptives therapy (OCT) was 10 years (range 3-23). The average age of patients at the time of oral contraception was 30 years. The 13 women had also 17 pregnancies without any venous thrombosis. The observations casts several doubt about the prothrombotic effect of this polymorphism. Since DVT has been shown to occur occasionally even in normal women, it is likely that the same may occur in women with this polymorphism regardless of the existence or not of any pathogenetic relationship between the two phenomena. Occasional reports suggesting a link between this polymorphism and oral contraception-related venous thrombosis should be carefully evaluated in order to avoid premature and incorrect conclusions.

Although pharmacologic prophylaxis against venous thromboembolism has become the standard of care following total hip and knee replacement, prophylaxis among patients undergoing surgery for hip fracture and other lower extremity trauma remains underutilized. Available experience consistently supports the view that low-molecular-weight heparins are more effective than unfractionated heparin for prevention of proximal deep vein thrombosis (DVT) with no additional hemorrhagic risk and more effective than oral anticoagulants for prevention of in-hospital (mostly distal) venous thrombosis at the price of a higher surgical site bleeding and wound hematoma. The choice between low-molecular-weight heparin and warfarin should be tailored to the individual patients based on the clinical assessment of postoperative thrombosis and bleeding risk as well as the prophylaxis-specific cost and convenience. Whether thromboprophylaxis should be continued for a few additional weeks after hospital discharge is controversial. The overall incidence of postoperative DVT in patients with cancer is about twice as high as that of patients free of malignancy. Accordingly, they require prophylactic measures comparable with those usually recommended for major orthopedic surgery. In this setting, dermatan sulfate shows promise. In contrast to surgical patients, prevention of venous thromboembolism is less well studied in hospitalized medical patients. In a recent controlled randomized trial, enoxaparin in high prophylactic doses was an effective and safe measure of thromboprophylaxis in ordinary bedridden patients.

We found no case-control studies on dental extraction in haemophilia patients in the literature even though the use of antifibrinolytic agents following a single infusion of factor VIII or IX has been accompanied by a lower number of bleeding complications in dental extractions. In this study we verified the incidence of bleeding complications after dental extraction in a group of 77 haemophilia patients. One hundred and eighty-four male patients requiring dental extraction represented the control group. All haemophilia patients received 20 mg kg-1 of tranexamic acid and a single infusion of factor VIII or IX to achieve a peak level about 30% of factor VIII or IX in vivo prior to dental extraction. Forty-five of 98 (45.9%) dental extractions in haemophilia patients and 110 of 239 (46%) dental extractions in the control group were surgical ones. We registered two bleeding complications in the group of haemophilia patients (one late bleeding and one haematoma in the site of the anaesthetic injection) and one (a late bleeding) in the control group. The difference of bleeding complications in the two groups of patients were not statistically significant (P=0.2; OR 0.2; CI 0.01-2.22). The protocol proposed in this study, characterized by the feasibility and the number of haemorrhagic complications not different from normal population, make dental extractions in haemophilia patients possible on an out-patient basis with a cost reduction for the community and minor discomfort for the patients.

The patients' movement in bed, is a procedure that demand great physical effort and use of good corporal mechanics for the nursing personnel, relative of preventing them back pain problems. Recognizing the importance of the movement and positioning, to promote safety and comfort to the patient, and before the professionals' complaints, described in the literature, this work has for objectives: to identify and analyzer the postures assumed by the nursing workers and identify the means and difficulties found during the execution of the referred activity. Through the technique of direct observation they were filmed, through videotapes, thirty procedures of patient's movement in the bed executed by nursing workers of an orthopedic clinic of an university hospital. The results evidence that the thirty procedures were executed along 197.41 minutes and that the corporal postures more frequently assumed they were, in respect to back, arms and legs, back inclined/arms with elbow down of row of seats/legs extension (53.76%). In agreement with the beginnings of the corporal mechanics and of the ergonomics, such postures are considered painful to the man, due to the muscle-skeletal aggressions and to the physical overload that they cart. The workers aimed the aspects little space (58.82%), physical load (52.94%) and absence of the personal (47.06%), as the main difficulties found in the execution of patient's movement in the bed, corroborating with the discoveries of the literature, characterizing that activity as painful. They pointed: the adequate technique (36.29%), used of sheet (35.29%) and space adequate (23.52%), as aspects that would facilitate the execution of the procedure.

Three hundred and forty-three consecutive patients with deep vein thrombosis (DVT) were investigated for the possible presence of occult or undiagnosed cancer, of whom 305 patients had DVT of the lower limbs whereas 38 had DVT of the upper limbs. Cancer was diagnosed during a 12-month follow-up in nine patients with DVT of the upper limbs (23.7%) and in 34 patients with DVT of the lower limbs (11.1%). The difference was statistically significant. Furthermore, it was shown that the majority of cancers (seven of nine) in the case of DVT of the upper limbs were discovered during the first week of hospital admission. In contrast, in the case of DVT of lower limbs, only eight of 34 cancers were discovered during the initial investigation. Lung cancer and lymphomas represented the majority of cancers associated with upper limb venous thrombosis (seven of nine). In the case of DVT of the lower limbs, cancers were heterogeneous; however, 12 of 34 were cancers of the colon or prostate.

To establish the prevalence of antibodies against beta2-glycoprotein I (beta2GPI) in unselected patients with venous thromboembolism, as well as the association with antiphospholipid antibodies (aPL) and a history of previous thromboembolism, we investigated the presence of these antibodies in 227 consecutive patients with acute deep vein thrombosis or pulmonary embolism, of whom 63 were carriers of aPL with or without lupus anticoagulant (LA), and seven were carriers of LA alone. The presence of antibodies against beta2GPI was demonstrated in 19 patients [8.4%; 95% confidence interval (CI), 4.5-11.3%]. All of them belonged to the group of 63 patients with aPL (30.2%). A history of a previous thromboembolism was identified in 11 of the 19 patients with anti-beta2GPI antibodies (57.9%) and in 45 of the 208 patients without these antibodies [21.6%; odds ratio (OR)=4.98; 95% CI, 1.89-13.1; p<0.0005]. In the subgroup of patients with aPL and/or LA, the rate of recurrent thromboembolism among patients with anti-beta2GPI antibodies (11 of 19, 57.9%) was significantly higher than that observed in patients without these antibodies (15 of 51, 29.4%; OR=3.3; 95% CI, 1.1-9.83; p=0.28). We conclude that in patients with acute venous thromboembolism the prevalence of antibodies against beta2GPI is unexpectedly high. The presence of these antibodies seems to identify a subgroup of patients with antiphospholipid antibodies who have a peculiarly high risk of thrombotic recurrences. Further prospective studies are indicated to better define the role of anti-beta2GPI antibodies in the development of recurrent thromboembolism.

Atherosclerosis is a multifactorial disease caused by genetic and environmental factors with important clinical sequelae. The aim of this study was to evaluate the degree of carotid atherosclerosis by echo-color Doppler scan in a group of patients affected by hemophilia A and von Willebrand disease versus a group of normal subjects apparently free of atherosclerotic risk factors. All coagulopathics and normal patients who came to our Internal Medicine Department (Padua Hospital) underwent physical exam, blood analysis, standard electrocardiogram, chest x-ray, echo-color Doppler scan, and a thorough history. We examined 156 subjects, 76 coagulopathics (46 men, 30 women) and 77 normals (37 men, 40 women). Coagulopathics were affected by hypertension in 28.9% of cases, diabetes mellitus in 6.5%, dislipidemia in 17.1%, smoke in 39.4%, and obesity in 36.8% (p < .05). Echo-color Doppler scan revealed carotid plaques in 27.2% of control patients versus 13.1% of coagulopathics (p < .05). Hemophilics and subjects with von Willebrand disease with a more serious illness had fewer plaques than those with lighter defects. Coagulopathics showed 23.6% of the plaques we revealed on the whole, versus 76.3% of control subjects (p < .01), with a lighter degree of stenosis (p < .01). Our data demonstrate that patients with hemophilia A and von Willebrand disease have fewer carotid plaques and a smaller degree of carotid stenosis than normal subjects of the same sex and age. These data seem to strengthen the hypothesis that blood coagulation defects may allow protection against carotid atherosclerosis and its sequelae.

The aim of this study was to investigate whether the immune system of patients with hemophilia A is skewed toward an aspecific activation and to identify the causative factors. It is well known that an immune derangement does exist in patients with hemophilia A. At least three factors potentially play a role: hepatitis C virus (HCV) infection, alpha-interferon therapy and the administration of factor VIII (FVIII). Sixty human immunodeficiency virus (HIV)-negative patients with severe or moderate hemophilia A were studied retrospectively. The serological markers of autoimmunity were evaluated and the results correlated with anti-HCV antibodies, FVIII treatment and alpha-interferon therapy. The role of these factors in the development of the anti-FVIII antibody was estimated concomitantly. The prevalence of autoantibodies and anti-FVIII antibodies was higher in HCV-positive than in HCV-negative patients before any treatment, although the difference was not statistically significant. The administration of FVIII further influenced the development of autoantibodies both in HCV-negative and HCV-positive patients, with no difference being observed between the two groups. As expected, fewer HCV-negative than HCV-positive patients developed anti-FVIII antibodies after administration of FVIII (31.8% versus 38%, respectively). Therapy with alpha-interferon did not seem to enhance significantly the risk of developing autoantibodies nor anti-FVIII antibodies. We observed a high prevalence of humoral signs of autoimmunity among patients with hemophilia A. Treatment with FVIII concentrate is probably the most important triggering factor. Monitoring these patients for autoimmune manifestations is recommended.

The development of inhibitor antibodies is one of the more important complications in the management of haemophilia patients. In a previous study, the prevalence of inhibitor varies between 5 and 52%, seems to be different for different types of concentrates, and is less frequent in multitransfused patients. In our prospective study we followed for 3 years 62 multitransfused haemophilia patients without inhibitor or past history of inhibitor. Thirty-seven haemophilia patients were treated with intermediate purity factor VIII concentrates, whereas 25 were given high purity concentrates (from the eighth month of the study five of these patients were treated with recombinant products). Factor VIII inhibitor antibody developed in seven of 25 haemophilia patients treated with high purity concentrates or recombinant products, whereas none of the haemophilia patients treated with intermediate purity concentrates had inhibitors. The difference was statistically significant (P < 0.001; OR = 0.06, 95% CI 0.001-0.3). In all patients, the titre of the inhibitor was low and no problem occurred in their management. Since inhibitors appeared in multitransfused patients when transfused with high purity concentrates and/or when the patients were switched to recombinant FVIII product, the development of inhibitor seems to be due to the administration of a new concentrate. Therefore this potential complication must be considered every time a new concentrate is administered.

A patient with combined factor V and factor VII deficiency is described together with a family study. The propositus appeared to be double heterozygous for factor V and factor VII deficiency. Since the patient showed a parallel decrease of activity and antigen, he appeared to be double heterozygous for a true deficiency. The patient had inherited the factor V defect from the mother and the factor VII defect from the father. The parents of the propositus were not consanguineous. Other family members were found to have isolated factor V or factor VII deficiency. This is the third family so far described with this peculiar combined defect but the first to be investigated by clotting and immunologic assays.

Although haemophilia is a relatively rare hereditary disease, and is curable by blood products, the psychological and social problems of haemophilic patients and of their families are always serious. Anxiety for the risks of bleedings and the fear for infections transmitted by blood products cause stress and difficulty in coping with the situation. The aim of this paper is to assess resources, stress, and coping in parents with a haemophilic child. In order to measure the dimensions related to family stress and resources, social desirability, tendency to depression, and anxiety, the subjects were administered the short-form of the Questionnaire on Resources and Stress by Friedrich et al. revised by Saviolo & Cristante, along with the Social Desirability Scale, the Beck Depression Inventory, and the Ipat Anxiety Scale. The subjects of this study were 20 couples who were the parents of haemophilic sons. We analysed how the parents perceived the behavioural characteristics of their child, the differences between mothers and fathers in the questionnaire scores, and the correlation among the considered dimensions. The results show that the parents paid great attention to the problems of their sons, but mothers were more depressed and anxious about the disease of their child.

Hysterosalpingography with selective salpingography is by now a well-established technique in the diagnosis and therapy of some forms of female sterility especially in relation to tubal disease. The experience with a group of 302 patients with unilateral (187) or bilateral (115) proximal tubal disease, is reported. As for the catheterization of obstructed tubes, the technique was successful in about 94% of cases, while failure was observed in 6% of cases due to organic disease which hindered the transit of the angiographic guidewire or catheter. 10% of all the patients achieved spontaneous pregnancy while artificial insemination was performed in 15%. A 12-month follow-up of 10 women undergoing hysterosalpingography showed in approximately 60% of cases a new uni-or bilateral proximal tubal obstruction. No immediate or late severe procedure-associated complications were observed. Extrauterine pregnancy occurred in 2% of cases, probably due to the restored patency in tubes lacking physiologic motility.

Aims/background: TIPS, an effective procedure applied for the treatment of complications of portal hypertension, is potentially followed by worsening of the hyperdynamic circulation of cirrhosis and the impairment of liver function. The aim of the present study was to evaluate short-term changes of functional liver plasma flow after application of TIPS, using the hepatic (extrarenal) clearance of D-sorbitol (S-HCl)., Methods: Twenty-five cirrhotic patients submitted to TIPS for prevention of variceal rebleeding entered the study. At steady-state, during constant infusion of a solution of D-sorbitol (25 mg/min), appropriate blood and urine samples were collected in order to calculate S-HCI before and 120 min after TIPS opening. In addition, the hepatic extraction ratio of D-sorbitol was directly measured at the level of the right (Er), where TIPS was applied, and of the left (El) hepatic veins; meanwhile the portocaval gradient (PCG) was registered, before and after stent dilation. A comparison of values obtained before and after TIPS application was performed by Student's t-test for paired data., Results: After application of TIPS, a substantial reduction was observed in PCG (12.1+/-4.2 vs 24.8+/-4.3 mmHg; p<0.001) and Er values (20.6+/-14.8 vs 57.5+/-22.3 %; p<0.001) but not El values (47.4+/-22.0 vs 53.4+/-21.4 %; p=0.178). S-HCl measured 120 min after TIPS opening was not statistically different from pre-TIPS values (389.2+/-212.1 vs 394.6+/-152.7 ml/min; p=0.892), although S-HCl variations in Child-Pugh class B patients were positively correlated with portal pressure variations (r=0.63, p=0.016)., Conclusion: Our results demonstrate that in patients with advanced cirrhosis, TIPS procedure, while effective in reducing portal hypertension, does not lead to alterations in the functional liver plasma flow within the first 2 h.

Background: The purpose of this work is to show the effectiveness of percutaneous embolization therapy in the treatment of visceral arterial pseudoaneurysms and to propose the method as a valid alternative to surgery., Methods: Twenty-eight patients with visceral artery pseudoaneurysms were treated: 10 of them were hepatic; 9 renal; 7 duodenal-pancreatic; 1 splenic and 1 of the celiac trunk. Materials employed were: Gianturco metallic coils, Spongostan and Poli-Vinyl-Alcohol., Results: Immediate success was obtained in all cases; recurrences occurred in 5 patients (18%) and they have all been successfully retreated with percutaneous method; complications occurred in 3 patients (10%) and they were all directly related to the pre-existing pathology and not to the percutaneous treatment., Conclusions: To obtain the best results from embolization, it is necessary to respect some conditions regarding the correct choice of embolic materials, the superselective catheterization of the injured artery and the low injection pressure of the contrast medium in order to avoid rupturing the thin pseudoaneurysmatic wall. The advantages of the percutaneous treatment are: less trauma, local anesthesia, reduction of the time between diagnosis and therapy, reduction of hospitalization stay and limitation of parenchymal destruction, Complications are relatively not frequent and in no cases the percutaneous therapy compromised the surgical intervention when it became necessary.

Introduction: We report our personal technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir (Port-a-cath) for the regional chemotherapy of hepatic and extrahepatic tumors. January, 1996, to February, 1997 fifty patients underwent the procedure: 44 had liver cancers (42 had metastases and 2 hepatocellular carcinomas), 4 pelvic tumors (2 bladder carcinomas, one uterine cancer and one vaginal cancer), one had inoperable pancreatic tumor and one breast cancer., Materials and Methods: The access was the left axillary artery in 45 cases, the femoral artery in 4 and both the femoral and the axillary artery in one case. The infusion catheter was placed in the hepatic artery in 44 cases, in the splenic artery in one case of pancreatic cancer, in the hypogastric artery in 4 cases and in the internal mammary artery in one case. When the catheter was positioned in the hepatic artery, embolization of the gastroduodenal or accessory hepatic arteries was performed using metallic coils; when the catheter was positioned in the hypogastric artery, the contralateral hypogastric artery and the ipsilateral gluteal branches were embolized. The catheter was then tunnelled and connected to a subcutaneous reservoir, sutured to the pectoral fascia or to the inguinal ligament. After the injection of heparinated solution, infusion chemotherapy was started the day after the procedure., Results: We obtained immediate technical success in all cases. Four major complications occurred: a pseudoaneurysm of the left axillary artery (percutaneously treated by placement of a covered stent), 2 thromboses of the hepatic artery and one case of gastritis. Among minor complications, the catheter was displaced in 9 cases and 7 catheters were percutaneously replaced. Side-effects, not related to the procedure, were pain, nausea, vomiting and mucositis. During the follow-up, 7 patients died (6 for tumor progression); median catheter patency was 5.14 months. Though the aim of this work is to present the technical aspects of the procedure, we report the preliminary clinical data: radiological examinations showed partial tumor regression in 15 of 33 patients with 3-month follow-up; no change was shown in 2 patients and disease progression was found in 4; the response could not be assessed in the other cases., Conclusions: In conclusion, the percutaneous placement of intraarterial catheters for continuous regional chemotherapy is a feasible, safe and tolerable procedure and can represent an alternative to the surgical implantation of catheters in the hepatic artery for the treatment of liver metastases from colorectal cancer. The technique opens new therapeutic possibilities for the local treatment of extrahepatic tumors (such as gynecologic, vesical, pancreatic and breast cancers), even though its clinical efficacy must be assessed in selected trials.

Factor V antigen levels were measured in 40 patients with factor V deficiency (11 homozygous and 29 heterozygous), in 38 patients with factor V Leiden mutation (16 homozygous and 22 heterozygous) and in three patients with combined heterozygous factor V deficiency and heterozygous factor V Leiden mutation (so-called pseudohomozygosis for APC resistance). Twenty normal subjects of both sexes served as controls. Factor V antigen levels compared well with factor V activity in normal subjects and in all groups of patients. They were normal both in homozygous and heterozygous APC resistance patients. Factor V antigen determination may be useful for the diagnosis of pseudohomozygosis for APC resistance. These patients have a phenotypic picture similar to homozygous APC resistance, but show a factor V antigen level about half the normal value since they are compound heterozygotes for factor V deficiency and APC resistance. In contrast, homozygous patients for APC resistance show normal factor V activity and antigen levels.

Background/aims: Peripheral vasodilation represents the main vascular dysfunction associated with the hyperdynamic circulation of liver cirrhosis. This study was intended to measure directly regional and systemic levels of nitric oxide, a potent vasorelaxing mediator, in order to assess its role in the development of hemodynamic changes of cirrhosis., Methods: We compared nitric oxide levels in the splanchinic and systemic circulation of 25 patients with cirrhosis undergoing transjugular intrahepatic portosystemic stent shunt and in the hepatic vein and peripheral blood of 10 patients without cirrhosis submitted to venous catheterization. Nitric oxide levels were measured through electron paramagnetic resonance spectroscopy as nitrosylhemoglobin complexes., Results: Significantly higher nitric oxide levels were calculated in patients with cirrhosis with respect to controls, both in the peripheral and hepatic veins. In patients with cirrhosis, nitric oxide levels in the portal vein (3.44 +/- 2.17, expressed in arbitrary units) were higher than in the systemic circulation (1.89 +/- 1.15), but lower than in the hepatic vein (4.75 +/- 2.53; p < 0.001 by variance analysis)., Conclusions: These data suggest that nitric oxide synthetic pathway activity as well as nitric oxide release are enhanced at the level of splanchnic vasculature and, more important, in the hepatic tissue, confirming evidence of the predominant role of nitric oxide in the pathogenesis of hemodynamic changes in patients with cirrhosis with portal hypertension.

There is a renewed interest in locoregional chemotherapy for hepatic tumors; trials in progress are experimenting with new therapeutic protocols with an approach combining different systems of infusion (HAI and systematic) or with the use of HAI as adjuvant or neoadjuvant of the surgical treatment or cryosurgical treatment of the hepatic metastases from colo-rectal cancer. However, HAI is practicable principally with the implantation of a catheter in the hepatic artery (port of Infusaid) by laparotomic access. This intervention limits wide-scale use of the infusion method, traditionally less toxic and more efficient in terms of results than systemic treatment. Limited experience of percutaneous access for HAI required more catheterisation with repeated puncturing of the artery and later necessity of surgery in cases of HAI with continuous spraying. Motivated by the first experience of certain authors from Chiba University, we have devised a system of catheterisation of the hepatic artery with transcutaneous access, with subcutaneous port that allows the use of HAI without recourse to the usual intervention. Access is made through the left axillary artery; the positioning of the catheter is in the hepatic artery with possible embolization of the collateral or abnormal hepatic artery that could hamper complete diffusion of the drug to the liver, or increase to toxicity of the method. The implantation is done in day-surgery. In the cases performed up to now there have been no complications regarding the method and the catheters function all perfectly thanks to the collaboration of ematologists to avoid possible thrombosis of the catheters.

Background: A definite evidence in favour of an association of deep-vein thrombosis (DVT) with lupus anticoagulant (LA) in patients free from systemic lupus erythematosus is still lacking., Methods: In a case-control study, LA was determined in 176 consecutive outpatients who underwent phlebography because of the first episode of clinically suspected DVT of lower limbs. The association between DVT and LA was described using odds ratios (OR)., Results: Contrast venography confirmed the clinical suspicion in 59 patients (33.5%). LA was detected in 5 of the 59 patients with DVT (8.5%), and in none of the 117 subjects with normal venogram (P = 0.007). The OR for having an acute DVT in patients with LA was 10.7 (95% CI: 1.2-94.2)., Conclusions: LA is significantly associated with DVT in symptomatic patients. Further studies are needed to establish the clinical implications of this association.

The role of oral contraceptives as a triggering factor for thrombosis in patients with lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACA) has not yet been established. We describe the cases of three women aged 19, 29 and 48 years who developed venous thrombosis after 16 +/- 3.4 (mean +/- SD) cycles of oral contraceptives. They were all asymptomatic before taking the pill. Two patients subsequently developed venous and/or arterial recurrence of thrombosis. Laboratory studies performed after the diagnosis of thrombosis, showed the presence of LA and elevated levels of ACA (IgG and IgM) in all three patients. None of these patients had autoimmune diseases and therefore appeared to have a primary antiphospholipid antibody syndrome. The three patients belonged to a group of 45 young females who experienced their first thrombotic event while taking the pill. This group had a similar prevalence (8%) for antithrombin deficiency and antiphospholipid antibodies. We surmise that some of the women who developed venous thrombosis while taking the pill might have an undetected primary antiphospholipid syndrome.

Tissue thromboplastin inhibition assay (TTI) is a sensitive test for lupus anticoagulant (LA). We have performed TTI in 12 LA positive patients using a new recombinant human tissue factor (Innovin, IN) and compared it with Thromborel S (TH), a commonly used human placenta thromboplastin. The effect of using two different dilutions of each thromboplastin (1:10 & 1:26) was investigated. A 1:26 dilution discriminated better than the 1:10 and this was more evident for Innovin. The mean value obtained with a 1:26 IN dilution was statistically different from that observed with TH at the same dilution. Furthermore, when PT and TTI ratios were considered, differences were statistically significant and seemed to increase depending on thromboplastin dilutions. When we used IN at 1:26 all LA positive patients had a value > 1.2. Then we compared TTI at a 1:26 dilution with dilute Russell's Viper Venom Time (dRVVT) in 50 consecutive patients with suspected lupus anticoagulant not treated with warfarin or heparin. In these patients the diagnosis of lupus anticoagulant was carried out using dilute APTT mixing studies and a platelet neutralization procedure: four out of 50 patients thus tested were LA positive. When dRVVT or TTI-I 1:26 were used, five patients were positive for lupus anticoagulant. Innovin showed similar sensitivity of dRVVT for detection of lupus anticoagulant. It is likely that higher dilutions of thromboplastins could further improve the specificity of this method.

Resistive index (RI) calculation on Doppler tracing of intrarenal arterial blood flow is a sensitive method for the early diagnosis of obstructive uropathy. However, the RI is not specific and can increase in a number of other conditions, e.g., old age, circulating endogenic factors or drugs, other nephropathies. The authors investigated RI usefulness and accuracy by measuring it both before and after the radiologic treatment of acute urinary obstruction in 21 patients, 9 of whom had chronic renal failure due to other causes, i.e., hypertension, diabetes and chronic pyelonephritis. The clinical conditions of the patients limited the feasibility of RI measurements before and after nephrostomy to 66%. In 22 kidneys in 17 patients examined before nephrostomy, the RI ranged 0.63 to 0.93 (mean: 0.80); when the obstruction was unilateral, the RI was always higher than in the contralateral kidney. In 25 kidneys in 18 patients examined after nephrostomy, the mean RI value was 0.68 (15% lower than before). Taking 0.7 as the cut-off value, RI sensitivity in detecting acute urinary obstruction was high (about 90%), while its specificity was low (about 50%); specificity increased (to about 80%) when other concomitant causes of increased intrarenal arterial resistance, e.g., other vascular or parenchymal nephropathies, were not considered. In some cases, the method was also useful in excluding the presence of recurrent obstruction after ureteral stent removal. In conclusion, Doppler US values of intrarenal arterial perfusion are indicative of acute urinary obstruction when they can be compared with those from the contralateral healthy kidney or when they can be measured, in the same patient, before and after decompressive nephrostomy. In other cases, other nephropathies and some technical limitations must be considered.

Percutaneous gastrostomy is reported to be an effective alternative to total parenteral feeding or long-term nasogastric tube in the treatment of mechanical or functional dysphagia. The authors report their personal experience with 137 percutaneous gastrostomies performed on 98 men and 39 women from January 1986 through December 1993. All the maneuvers were performed under fluoroscopic guidance in the patients with head or neck cancer, neoplastic, vascular or post-traumatic neuropathy and upper GI tract cancer. To avoid left hepatic lobe trauma, percutaneous gastrostomy needs to be performed under US guidance. A 7F nasogastric tube is used to fill the stomach with air. After distending the gastric cavity, with the Seldinger technique under local anesthesia, fascial dilators of progressively increasing caliber are introduced into the gastric cavity and the final 12F gastrostomy catheter is positioned under fluoroscopic guidance. No major complications, such as hemorrhage or peritonitis, occurred. In one case, during the maneuver, the patient complained of severe epigastric pain which regressed with no further problems two hours later. In three cases the gastrostomy catheter fell out of place and was replaced by running the fistolous tract with a venous cannula and then a guidewire for gastrostomy repositioning. With this type of treatment, the patient can be given enteral feeding the following day. The maneuver requires approximately 10 minutes to perform and is well tolerated by the patient as it requires no general anesthesia. Percutaneous gastrostomy is more cost-effective than surgery or endoscopy and hospitalization is shorter. The only contraindications to this maneuver are hepatomegaly (because of the risk of liver trauma during percutaneous maneuvers), ascites (because of the risk of infection) and finally the complications resulting from gastric resection.

Cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumor) is a slowly growing malignancy with early onset of symptoms and poor outcome since surgery allows radical resection in only a minority of cases. Percutaneously placed biliary stents offer a good palliation, but tend to obstruct after 6-8 months; then, retreatment requires exchange of the endoprosthesis or establishment of a permanent external-internal biliary drainage which offers, in some patients, a relatively long survival. Percutaneous intraluminal HDR brachytherapy might be a valid alternative as a definitive therapy or as a method to keep metallic stents patent for a long time. Five patients with hilar cholangiocarcinoma, diagnosed by means of ultrasound, Computed Tomography, percutaneous transhepatic cholangiography and transluminal biopsy, underwent double percutaneous external-internal biliary drainage. Dummy sources were introduced into the drainage catheters to allow dose distribution planning. The stepwise progression of the miniaturized high activity Iridium source inside the applicators, introduced into the drainage catheters, was controlled and monitored by a computer equipped with dedicated software. In the radiotherapy bunker, using the remote loading technique, percutaneous intracavitary high dose rate brachytherapy was delivered at the rate of 750 cGy per fraction, prescribed at 1 cm from the center of the catheter, once a week, for 4 weeks. Nevertheless, only 4 of 5 patients underwent the complete treatment. In one case, radiation treatment was discontinued after the first session because of digestive bleeding from a duodenal ulcer, supposingly as a consequence of the decubitus of a catheter tip. CT demonstrated rapid progression of the disease with neoplastic spread to the omentum and gallbladder wall thickening; a gallbladder malignancy was then suspected and the patient was no more eligibile for brachytherapy. Subsequently, Carey-Coons endoprostheses were inserted to prevent post-actinic strictures and removed after three months. After completing radiation therapy, control cholangiograms demonstrated in all cases improvement of neoplastic strictures. The first two patients we treated show no signs of tumor recurrence at 4 and 1 months, respectively, after endoscopic removal of the stents. The third patient is still bearing 2 Carey-Coons endoprostheses to be removed after 3 months. The last patient with supposingly partial success of bracytherapy, was treated with two Strecker nitinol stents.

CT-guided stereolithography provides an acrylic model which exactly replicates the original structure. It allows optimal preoperative planning and intraoperative management. This application proved advantageous in surgical correction of a wide midline craniofacial cleft in a baby.

13 patients with HIV-related immune thrombocytopenia (HIV-ITP) and 10 patients with chronic idiopathic thrombocytopenic purpura (C-ITP) were treated with a single course of alpha-2b-Interferon (IFN 3 x 10(6) IU subcutaneously for 12 d). The patients had platelet counts lower than 40 x 10(9)/L and thrombocytopenia persisting for over 1 year (range 1-22 years); 7 patients were refractory to previous conventional therapy, 5 were responsive, and 11 had not been previously treated. The response to IFN was complete in 8 patients (platelets > 100 x 10(9)/L), partial in 7 (platelets 50-100 x 10(9)/L); 8 patients showed no response. The treatment with IFN was stopped after 4 d in one patient due to a fall in platelet count. The maximal platelet count (median peak 116 +/- 55 SD x 10(9)/L platelets) was obtained after 13.7 +/- 2.98 d and the improvement in platelet count was maintained for 22.8 +/- 8.6 d. No difference in platelets response was observed between HIV-ITP and C-ITP. The response to IFN seems to be related to the one obtained with previous treatments. Indeed 80% of the patients who were responsive to previous steroids, high dose immunoglobulins or azidothymidine (HIV-ITP) showed a complete or partial response while only 43% of the refractory patients showed a partial response; the positive response rate in previously untreated patients was 73%.

Renal transplantation is considered the treatment of choice in most cases of renal failure; the urologic complication rate ranges 1 to 10% in different surveys. This work was aimed at evaluating the application and results of interventional radiology in these cases. Since 1983, 24 patients (20 males and 4 females) whose age ranged from 18 to 63 years (mean age: 42 years) have been submitted to percutaneous maneuvers in our department. Thirty-four complications were treated: 14 stenoses, 11 fistulas, 7 urinomas and 2 transient obstructions. Complete success was obtained in 15/24 patients (62.5%), while 7/24 patients (29.16%) underwent reoperation and in 2/24 cases (8.34%) a definitive pyelostomy catheter was inserted. In 7 stenosis cases ureteroplasty was successfully performed and a double-J endoprosthesis inserted; the follow-up results (5-21 months) were satisfying in all cases. The only complication was one case of endoperitoneal hematoma. Considering the good results obtained, the low morbidity and mortality and the low cost, percutaneous maneuvers must be considered the treatment of choice in the urologic complications of renal transplants. When the percutaneous treatment of the main lesion fails, pyelostomy does nonetheless allow the drainage of urinary collections, the maintenance of renal function and the improvement of local and general conditions, which makes it easier to reoperate under elective conditions.

We report our experience with 49 patients who underwent fistulosphincterotomy (FS) after cannulation of the common bile duct (CBD) by standard approaches had failed, due to suspected CBD obstruction. Only 4% of our cases turned out to have no biliary obstruction at all. The morbidity rate was 16%, and the mortality rate was 2%. In our series, FS raised the success rate of CBD cannulation from 90% to 96%. Ninety-five percent of successful cannulations were followed by endoscopic treatment. There were no cases of perforation or hemorrhage, and no difference in the success rate between FS in flat papillas and FS in bulging papillas, thanks, perhaps, to the technique we used. Our findings would indicate that FS is a useful procedure involving additional but not prohibitive risks. Nonetheless, it should be used only when CBD obstruction is strongly suspected and standard methods are not successful.

Some complications of liver transplantation appear as aspecific clinical and blood test abnormalities; others--e.g., hepatic artery thrombosis in the immediate postoperative period and stenosis of the biliary anastomosis before T-tube removal--require early diagnosis. These considerations justify the need of frequent radiologic examination in both the complicated course and the follow-up. The authors report their experience in 59 adult patients submitted to liver transplantation for irreversible liver disease in advanced stage (49 with cirrhosis, 10 with HCC; 5 with cholestatic hepatopathy; 3 with fulminant hepatitis; 1 with Budd-Chiari syndrome; 1 with metastatic APUDoma). Two hundred and sixty-three radiological examinations were performed (Doppler US, CT, angiography and cholangiography) which showed numerous early and delayed complications: 13 of them were treated with interventional radiology maneuvers (US-or CT-guided percutaneous drainage of fluid collections, biliary drainage, bilioplasty, arterial transcatheter embolization). Our results demonstrate that diagnostic and operative radiology are essential for the success of liver transplantation; integrated imaging is particularly important in the diagnosis of complications, while interventional radiology techniques can be usefully employed in their treatment.

Ureteral diversions may be complicated by strictures, hydronephrosis, pyelonephritis, lithiasis, fistulas, etc. In the last 10 years, 103 patients with 133 urological postoperative complications underwent percutaneous treatment. Most of the patients had been treated by percutaneous antegrade drainage; afterwards, stricture dilatation, ureteral stenting and stone extraction were performed. In one case a Strecker metallic stent was employed. We have successfully treated 101 of 133 complications (75.9%), with only 27 failures (20.3%). Five cases (3.8%) of lithiasis did not require percutaneous treatment. The good results obtained, the absence of major complications, the low cost and the little discomfort for the patients confirm the leading role of percutaneous treatment in complicated ureteral diversions.

Since 1983 we have percutaneously treated 150 cases of bile duct lithiasis in which previous endoscopic maneuvers had been incomplete or unfeasible. Complete resolution of lithiasis was obtained in 139 of 150 patients. In 6 cases only partial success was obtained but symptoms subsided. In 2 cases the treatment failed and the patients underwent surgery. Minor complications were observed in 12.6% of patients and resolved either spontaneously or by percutaneous maneuvers. Mortality rate was 2%. After a follow-up period of 6-12 months, 9 patients had a recurrence, completely resolved with further percutaneous treatment. These cases never required surgery. We obtained the best results in patients with stones residual after cholecystectomy or a iatrogenic stricture of the biliary tree. We obtained good results in massive lithiasis with combined endoscopic, surgical and radiological procedures. Morbidity and mortality rates were lower than in surgical series and similar to the endoscopic ones. The short hospitalization, the low cost and the possibility of treatment on an outpatient basis should promote the spreading of percutaneous techniques in the treatment of bile duct lithiasis.

Fallopian tube catheterization with selective ostial [correction of osteal] salpingography is a new technique for the diagnosis of tubal factors of infertility and also for the treatment of proximal tubal occlusion (PTO). In this study, 246 women were considered, 20-42 years old, with primary or secondary infertility, who presented a unilateral or bilateral PTO at hysterosalpingography (HSG). Catheterization and selective salpingography have been successful in 93.9% of the cases. Failures (5.6%) have been ascribed to obstructive organic diseases, where it was impossible to overcome the stenosis with the catheter or the guide-wire. Twenty-six spontaneous pregnancies were obtained (15 full-term deliveries) and 17 patients became pregnant after GIFT (13 full-term deliveries). At follow-up, after 12 months 4 of 10 patients had normal tubes, while 6 patients presented a new unilateral or bilateral PTO. No major complications occurred; nevertheless, ectopic pregnancy is a possible event, because of the mechanically re-established patency in a nonfunctioning tube.

Intralesional steroid injection in the treatment of hypertrophic scars and keloids has been well known for many years. In order to determine whether this therapy can still be recommended, 57 patients with hypertrophic scars or keloids received high-pressure injections of triamcinolon acetonide (Dermojet). 50% of the cases showed significant improvement with respect to scar color, itching and scar elevation. Thus, triamcinolon acetonide therapy is indicated in particular cases.

The technique of percutaneous transhepatic sphincterotomy is described. This procedure was employed in 3 patients with common bile duct (CBD) stones in whom a previous attempted endoscopic procedure had failed for anatomical reasons (a Billroth II gastric resection or a partial gastric resection with Braun anastomosis). Complete immediate success was obtained in all 3 patients. Furthermore, no major complications occurred during transhepatic treatment. The authors suggest that PTS be employed electively in patients with diseases of the biliary tree in whom the endoscopic approach fails.

The authors describe the technique employed for percutaneous transhepatic sphincterotomy as performed on 3 patients with common bile duct (CBD) stones. In all patients, previous endoscopic attempt had failed for anatomical reasons (Billroth II gastric resection or partial gastric resection with Brown anastomosis), and the ampulla could not be correctly incannulated with the sphincterotome. In all patients endoscopy was useful to check the position of the diathermic loop inserted percutaneously. Complete and immediate success was obtained in all 3 cases. No major complications occurred during transhepatic treatment. To date, 1 recurrence has been observed, and the patient has been retreated with bilioplasty. All patients were followed after 5-6 months with US, plain X-rays of the abdomen and blood tests (gamma Gt, alkaline phosphatase, and bilirubinemia). The authors suggest that percutaneous transhepatic sphincterotomy be employed electively in patients with biliary tree diseases in case the endoscopic approach failes.